2.0 Analysis 2.1 Introduction The examination of the helicopter revealed no evidence of any aircraft failure or system malfunction either prior to or during the flight. The pilot was certified and qualified for the flight in accordance with existing regulations, and there was no evidence that the pilot's performance was affected by physiological factors. This analysis will focus on the pilot's loss of visual reference, and, although not directly related to the cause of the accident, the chances of survival of the helicopter occupants, and the on-site safety monitoring system. 2.2 Loss of Visual Reference The flight was being conducted under visual flight rules, which require that the pilot maintain continuous visual reference with the ground or water. Because there were no aviation weather briefing facilities or weather observation personnel available at Leaf Rapids, pilots were required to assess local weather conditions themselves. At the commencement of the flight, the visibility of approximately three-quarters of a mile exceeded the minima required for VFR flight; however, as the helicopter was crossing the Churchill River, the smoke became more dense and the visibility deteriorated rapidly. The helicopter was equipped with basic instrumentation for VFR flight and was not certificated or equipped for single-pilot flight in IMC. The pilot had received instrument flight training early in his flying career, but he did not have an instrument rating, nor had he maintained instrument flying currency during the 15 years preceding the occurrence. As a result, neither the pilot nor the aircraft was certified or equipped to continue the flight in IMC; the only option available to the pilot was to attempt to maintain VFR. When the pilot decided that visibility conditions were no longer suitable to continue the flight, he elected to carry out a right turn over the river. During the turn, the pilot lost visual reference with the surface. After the accident, the visibility at the occurrence site was reportedly about 200 yards in smoke, the sky was obscured, and the water surface was observed to be flat and calm. This combination of conditions was conducive to spatial disorientation in VFR flight. The pilot had to rely solely on his manual control of the helicopter and on his interpretation of the aircraft's basic flight instruments to maintain control of the helicopter until he regained external visual cues. Upon losing visual reference, the pilot checked the flight instruments and noted that the vertical speed indicator showed that the helicopter was descending at 200 feet per minute. Descending at this rate from a height of about 75 feet, the helicopter would have taken only about 23 seconds to hit the water's surface. Since the pilot was not current in instrument flying, and the helicopter was not equipped for IFR flight, and there was a lack of identifiable outside visual references, the pilot had little chance of making a successful recovery. 2.3 Survivability The analysis of helicopter crash dynamics by Coltman documented the significant reduction in severe injuries incurred in helicopter crashes when people wore shoulder harnesses. The MNR Fireline Notebook also recognizes the benefit of using shoulder harnesses, and assigns the Helicopter Officer to monitor their use by pilots and passengers as a safety-related checklist item. The fact that the pilot, who was wearing both a shoulder harness and a protective helmet, survived the crash, while the other cockpit occupant did not, further highlights the increased level of protection provided by the additional safety gear. Forest-fire operations involve risk levels higher than those encountered on routine transportation flights. While it could not be proven that the wearing of shoulder harnesses or helmets would have changed the outcome for those passengers who did not survive this occurrence, there is sufficient evidence to indicate that the use of shoulder harnesses and protective headgear improves chances of survival. Use of shoulder harnesses and protective headgear might have prevented the incapacitation of the casualties in this occurrence. 2.4 Safety Management Transport Canada's regulations have been developed primarily to establish minimum safety standards for commercial and private air transport operations, and they do not specifically address the unique nature of forest-fire operations. Oil companies, many air ambulance services, and a number of agencies and departments from various levels of government have examined their flight operations requirements and determined the need to specify particular standards for the safety of their personnel, beyond the minimum standards required by Transport Canada regulation. These higher standards can be specified in the contract signed with the helicopter operator. The contract in effect at the time of the occurrence placed exclusive responsibility for safety standards with the helicopter operator, and only specified compliance with applicable regulations. The NTSB study advocates the establishment of compatible management policies and procedures in situations where two management structures (in this occurrence, MNR and Northern Mountain Helicopters) are involved together in operations of an urgent nature. The intent is for all operational personnel from both organizations to be operating to the same standards and limits. The NTSB study highlights the de facto management role that on-scene personnel have with helicopter pilots. This role places an onus on fire management organizations to establish a safety philosophy that includes flight operations. To a great extent, a similar philosophy and policies were already embodied in the MNR Fireline Notebook; however, personnel were not assigned to safety-related positions on the fire team. 3.0 Conclusions 3.1 Findings There was no evidence found of any aircraft failure or system malfunction either prior to or during the flight. Records indicate that the aircraft was certified and equipped for flight in VMC conditions in accordance with existing regulations. There was no evidence to indicate that the pilot's performance was affected by physiological factors. The pilot was certified and qualified for the occurrence flight in accordance with existing regulations. Although the pilot had instrument flight training early in his flying career, he did not have an instrument rating, nor had he maintained instrument flying currency during the 15 years preceding the occurrence, nor was he required to do so under existing regulations. There were no aviation weather briefing facilities or weather observation personnel available at Leaf Rapids, and pilots were required to assess local weather conditions themselves. The pilot lost the visual cues required for flight in visual meteorological conditions, and the helicopter struck the water before the pilot was able to regain adequate visual reference. Three of the eight persons on board were incapacitated by head injuries caused by the crash. They were unable to release their safety harnesses, and drowned. Studies indicate that the use of shoulder harnesses and protective headgear improves occupants' chances of survival in helicopter accidents; their use might have prevented the incapacitation of the casualties in this occurrence. MNR fire-team management guidelines provided for the establishment of safety-related positions on the fire team, but these positions were not staffed. 3.2 Causes While turning the helicopter to avoid an area of reduced visibility, the pilot lost the visual cues required for flight. The helicopter descended while in the turn and struck the water before the pilot was able to regain adequate visual reference. 4.0 Safety Action 4.1 Action Taken 4.1.1 Passenger Safety Equipment The Manitoba Ministry of Natural Resources has issued an internal operational guideline, effective as of the 1996 fire season, pertaining to all fire-fighting-related flights. The guideline requires persons on board such flights to wear seat-belts, shoulder harnesses (where available), and helmets or hard hats secured with a chin strap, except when performing duties that require the removal of any or all of these items. In addition, in its future long term contracts with helicopter operators, the Ministry will require that approved shoulder harnesses be supplied at all normally occupied seat locations; this specification will be a preferred item for all casual hire rentals of helicopters. 4.1.2 Fire Team Safety-Related Positions The Manitoba Ministry of Natural Resources has amended its operational guidelines to ensure that, on any overhead fire team mobilized to manage large fire outbreaks, the role of Fire Safety Officer is assigned to a specific and suitably trained individual. The Fire Safety Officer's responsibilities include complying with the items outlined in the Helicopter Officer Check List and ensuring that both pilots and other fire staff operate under the same standards and limits while on site. 4.1.3 Dissemination of Information The Board believes that others involved in managing the safety of forest fire operations should be made aware of the safety issues identified during this investigation and of the subsequent action taken by Manitoba's Ministry of Natural Resources. As such, the final report of this occurrence investigation is being distributed to the authorities responsible for forest fire management in each of the provinces and territories.